I will always remember a patient asking me when I was an attending on a trauma unit "Why is it that psychiatrists will restrain you but the won't hold your hand?" It was a heartbreaking moment and I simply did not know what to say other than to validate the dilemma.
Thank you for an excellent post! I'll be sharing this with my EM colleagues. This is a constant struggle for emergency department staff as we are rather the 'port of entry' to most psychiatric facilities. All of this made worse by endless holds that can last over a week (I'd get agitated too), combined with trying to keep our staff and patients safe. This is particularly true when they're on methamphetamine and other drugs which contribute to uncontrolled psychosis and agitation. (I personally believe there is a powerful synergism between modern higher concentrations of cannabis and methamphetamine.) We're pretty good at medical restraints, but sometimes it seems that there's no sedation we can provide that works for long, other than paralysis and intubation which are obviously terrible options.
I've done a lot of speaking around this internationally with emergency medicine colleagues + First responders. In the ER, at least you have the option of ketamine, Which I think is one of the least aversive of the options for Sedating people Who are severely agitated. I don't risk profile in the field, but in the ER, especially if you can ride someone out of a higher dose of ketamine with Expert an emergency medicine physician You have a much less Unpleasant alternative for the patient on your hands. That having been said, Verbal de-escalation using mentalization based approaches works just as well in the ER for emergency medicine doctor as it well for a psychiatrist, And keeps your staff safe also.
I'm curious to hear your thoughts and oral dexmetomidate, as that comes to market?
For what it's worth, one of my other pet theories is that a lot of ER education is nicotine withdrawal, And if we could just administer additional nicotine at the door to people who might go into withdrawal it would do a lot.
I am a huge ketamine fan, having used it for all levels of sedation over the years, from kid lacerations to intubated patients on the ventilator. Lately, in fact, I have used it with my intubations before I administer a paralytic. It allows me to take a look at the airway before I take away their respiratory drive, so I know that I'm about to face. I think that ketamine is underutilized for agitation in EM circles, likely because it is also a general anesthetic and many facilities view it with some (probably over-reactive) trepidation for that reason. When is the oral dexmetomidate coming to market? Oddly, I never developed a habit of using IV dexmetomidate while some of my colleagues use it regularly. However, I'd be keen to learn about using the oral version. I love the idea of nicotine withdrawal as a problem for this patient population. I hadn't considered that but it makes so much sense. I think physicians get very snarky about nicotine but it's highly addictive as many of our nurses know since they take regular smoking breaks. I'll be sure to be attentive to the nicotine patch when they arrive.
When I trained at MGH on the Psychiatric Consultation-Liaison service, we used a lot of IV dexmetomidate with agitated patients who were in the various ICUs, especially with delirium. We had one attending in particular who was especially knowledgeable about it
I use the trolley problem a lot when I talk with my patients, especially about how there are often no good choices but only a choice between two options, each with significant consequences. This is a great example and well written article about dealing with such a complex and nuanced topic. I once told a patient who was currently spending time with us on an involuntary admission, "it really sucks to have your choices taken away from you. I always feel bad because I want to be a doctor and not a jailer. If I were you I would be very angry too..." This small amount of validation changed the circumstances from a very angry and potentially violent patient to one who was willing to come in and spend a full hour in an assessment with me (and a very nervous med student).
I will always remember a patient asking me when I was an attending on a trauma unit "Why is it that psychiatrists will restrain you but the won't hold your hand?" It was a heartbreaking moment and I simply did not know what to say other than to validate the dilemma.
Thank you for an excellent post! I'll be sharing this with my EM colleagues. This is a constant struggle for emergency department staff as we are rather the 'port of entry' to most psychiatric facilities. All of this made worse by endless holds that can last over a week (I'd get agitated too), combined with trying to keep our staff and patients safe. This is particularly true when they're on methamphetamine and other drugs which contribute to uncontrolled psychosis and agitation. (I personally believe there is a powerful synergism between modern higher concentrations of cannabis and methamphetamine.) We're pretty good at medical restraints, but sometimes it seems that there's no sedation we can provide that works for long, other than paralysis and intubation which are obviously terrible options.
I've done a lot of speaking around this internationally with emergency medicine colleagues + First responders. In the ER, at least you have the option of ketamine, Which I think is one of the least aversive of the options for Sedating people Who are severely agitated. I don't risk profile in the field, but in the ER, especially if you can ride someone out of a higher dose of ketamine with Expert an emergency medicine physician You have a much less Unpleasant alternative for the patient on your hands. That having been said, Verbal de-escalation using mentalization based approaches works just as well in the ER for emergency medicine doctor as it well for a psychiatrist, And keeps your staff safe also.
I'm curious to hear your thoughts and oral dexmetomidate, as that comes to market?
For what it's worth, one of my other pet theories is that a lot of ER education is nicotine withdrawal, And if we could just administer additional nicotine at the door to people who might go into withdrawal it would do a lot.
I am a huge ketamine fan, having used it for all levels of sedation over the years, from kid lacerations to intubated patients on the ventilator. Lately, in fact, I have used it with my intubations before I administer a paralytic. It allows me to take a look at the airway before I take away their respiratory drive, so I know that I'm about to face. I think that ketamine is underutilized for agitation in EM circles, likely because it is also a general anesthetic and many facilities view it with some (probably over-reactive) trepidation for that reason. When is the oral dexmetomidate coming to market? Oddly, I never developed a habit of using IV dexmetomidate while some of my colleagues use it regularly. However, I'd be keen to learn about using the oral version. I love the idea of nicotine withdrawal as a problem for this patient population. I hadn't considered that but it makes so much sense. I think physicians get very snarky about nicotine but it's highly addictive as many of our nurses know since they take regular smoking breaks. I'll be sure to be attentive to the nicotine patch when they arrive.
When I trained at MGH on the Psychiatric Consultation-Liaison service, we used a lot of IV dexmetomidate with agitated patients who were in the various ICUs, especially with delirium. We had one attending in particular who was especially knowledgeable about it
there is now oral dexmetomidate in a dissolving strip for agitation
Very nice Owen.
I use the trolley problem a lot when I talk with my patients, especially about how there are often no good choices but only a choice between two options, each with significant consequences. This is a great example and well written article about dealing with such a complex and nuanced topic. I once told a patient who was currently spending time with us on an involuntary admission, "it really sucks to have your choices taken away from you. I always feel bad because I want to be a doctor and not a jailer. If I were you I would be very angry too..." This small amount of validation changed the circumstances from a very angry and potentially violent patient to one who was willing to come in and spend a full hour in an assessment with me (and a very nervous med student).
Thank you for the comment my friend. He also has videos on YouTube. https://youtu.be/Au-GnQmnngk
You beautifully capture how difficult the circumstances are--on all sides. Thank you for the insider's view.